The correlation between mechanical low back pain and foot overpronation

in patients referred to Hazrat Rasool Hospital

Azar Moezy *1, Sina Malaie2, Haleh Dadgostar1

Received: 2016/23/10 Revised: 2017/9/02 Accepted: 2017/13/03

1. Dept. of Sports Medicine, Iran University of Medical Sciences. Tehran, Iran

2. Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
Pars Journal of Medical Sciences, Vol. 14, No.4, Winter 2017

Abstract
Pars J Med Sci 2017; 14(4):51-61

Introduction:
Based on Janda’s theory of kinetic chain, dysfunction in one motor segment can affect other segments
in the body. The purpose of the study was to determine the correlation between low back pain (LBP)
and foot overpronation in patients presenting to Hazrat Rasool Hospital.
Materials and Methods:
In this case control study, 242 subjects were classified into two groups of LBP and healthy. The duration
and intensity of LBP, flexibility of trunk, foot overpronation (by Helbing sign and Navicular Drop test)
and ankle dorsiflexion range were evaluated. The independent sample t-test and Chi-square test were
used for statistical analysis of the data.
Results:
A significant correlation between was observed between foot overpronation and LBP (p=0.001). There
were significant relationships between LBP intensity and foot overpronation (p=0.001), between the
history of LBP and foot overpronation (p=0.001) and also between foot overpronation and ankle
dorsiflexion range (p=0.014).
Conclusion:
The findings of this study indicate significant relationships between the incidence, intensity and
duration of LBP in patients with foot overpronation. Furthermore, ankle dorsiflexion range was reduced
in the subjects with foot overpronation.

Keywords: Flat Foot, Longitudinal Arc, Navicular, Low Back Pain

Introduction
Low back pain (LBP) is one of the most conducted on the risk factors, prevention
common disorders of the musculoskeletal and treatment of LBP (1). Unfortunately,
system, leading to impaired function and LBP has also affected the young population
decreased quality of life in many patients. and its prevalence is increasing among
In addition, the disease incurs heavy children and adolescents.
economic costs on the patients and society. LBP is the second cause of disability in
Therefore, many studies have been adults and their visits to the doctor in the
* Corresponding author, Address: Dept. of Sports Medicine, Iran University of Medical Sciences. Tehran, Iran

Tel: +982164352446 Email: moezy.a@iums.ac.ir; azarmoezy@yahoo.com

51
The correlation between mechanical low back
United States. About 56%, 34%, and 14%
of the Americans are hospitalized because
of back pain for one day, six days, and one
month per year, respectively. Statistics
show that there are 149 million working
days lost due to LBP in the US that result in
200 million dollars of financial loss (2, 3).
LBP is one of the leading causes of absence
from work in the UK. About 17.3 million
people have LBP in the UK, of whom 3
million suffered LBP for more than a year
(4). There are no accurate statistics on the
incidence of LBP in Iran. The studies in
terms of developing LBP in Iran were
cross-sectional on small communities such
as employees, workers or pregnant women.
A study on the relationship between LBP
and physical activity in one of the
universities in Iran showed a prevalence of
86.3% (5). Another study on nurses in
Isfahan showed that 55.% of nurses had
LBP (6).
Attention to the numerous causes of LBP
plays an important role in the recovery
process (7). Causes of LBP can be
classified into mechanical, visceral,
inflammatory, infectious, tumors,
neuropsychological, and rheumatic
diseases (8, 9). Mechanical LBP is the most
common type of LBP (97%) in which
tissues such as bones, muscles, tendons,
ligaments, intervertebral discs, joints, and
nerves are damaged (10). Some causes of
mechanical LBP are sudden and intense
movements, spine trauma, postural and
biomechanical disorders of the spine,
biomechanical disorders of the lower
extremities, weak core muscles, tight back
and hip muscles, lower limb length
discrepancy, body weight gain, etc. (8, 9).
Biomechanical foot disorders are one of the
important factors affecting the incidence of
mechanical LBP. Foot overpronation is one
of the most common of these disorders
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017
Azar Moezy et al
mentioned in various medical sources under
a variety of titles such as foot
hyperpronation, flatfoot, heel valgus,
calcaneovalgus, etc. Foot overpronation is
known with the reduction or loss of the
medial longitudinal arch and is associated
with reduced dorsiflexion of the ankle and
other disorders such as heel valgus, mild
subluxation of the subtalar joint, calcaneal
eversion, and forefoot supination (11, 12).
The foot has a complex structure and the
normal placement of its components form
the foot arch. The arch spread the body
weight on the entire surface of the foot
when walking. It also absorbs the forces
exerted on the foot. The reaction force from
the ground to the feet increases in people
with a fallen plantar arch. In addition,
cushioning and absorption of impact forces
exerted on the foot are reduced, which can
predispose patients to complications such
as LBP, sacroiliac joint pain, hip pain, knee
pain, etc. (12-15). Common cause of a
fallen plantar arch are overweight, lack of
physical activity for a long time, aging,
standing occupations such as hairdressing
and dentistry, heredity, calf and leg muscle
weakness, leg muscle tightness, wearing
inappropriate shoes for a long time, such as
tight shoes, high heels and narrow shoes,
fractures in the foot, etc. (12).
In terms of biomechanics, the body
movement system is a set of kinetic chains
working together to make up a motion.
Kinetic chains are impaired due to postural
disorders, poor physical conditions,
repetitive patterns of movement, lack of
core stability, reduced flexibility,
biomechanical deformations, severe limb
movements, etc. Disorders in one part or the
entire kinetic chain impairs other kinetic
chains of the body, too. Hence,
biomechanical foot disorders such as foot
overpronation affect the entire lower
52
The correlation between mechanical low back
extremity kinetic chain system and the
spine causing severe back pain in some
cases (16, 17).
In a study on healthy subjects with
mechanical LBP, Brantingham et al. found
that a fallen medial arch is more probable in
patients with LBP (18).
Babaei et al. investigated the relationship
between LBP and foot disorders and found
a significant relationship between
increasing hallux valgus, hallux rigidus and
soleus muscle tightness with chronic LBP,
while they found no significant relationship
between foot dimensions and LBP.
However, they reported that ankle and foot
problems and deformities can cause back
pain due to their effects on posture, balance,
and walk (19).
Unfortunately, one of the prevalent
problems associated with LBP, especially
in young people, is lack of physicians’
attention to complete physical examination
and foot examination of the patients.
Medical centers mainly just prescribe
painkillers and non-steroidal and steroidal
anti-inflammatory drugs for patients
without performing a thorough physical
exam and only with questions about pain
regardless of the primary cause of pain and
discomfort to treat the symptoms of the
patients. While in most cases, the cause of
pain still exists and not paying attention to
it perpetuates pain and decreases the
physical function and quality of life of the
patients. It is clear that accurate diagnosis
of foot disorders and referring the patients
to specialists and using foot orthoses and
sports therapy can resolve the root cause of
this type of LBP and fully treat the patient.
There are few studies and insufficient
evidence about the relationship between
mechanical back pain and foot
overpronation in Iran. Therefore, the
present study tried to investigate the
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017
Azar Moezy et al
relationship between mechanical back pain
and foot overpronation.
Materials and Methods
This was a case-control study. The studied
population consisted of two groups of
patients with LBP and healthy controls
(accompanying people). They were
selected through convenience sampling
based on inclusion and exclusion criteria,
from 2015 to 2016 in the orthopedic and
sports medicine clinics of Hazrat Rasool
medical complex. This study was approved
by the Ethics Committee of Iran University
of Medical Sciences (Project No.
8721215095) and written consent was
obtained from all participants. The
inclusion criteria were: approved
mechanical LBP by orthopedists or sports
medicine professionals, aged 20-50 years,
BMI of 20-25 kg/m2, and willingness to
participate in the study. The exclusion
criteria were: a history of traumatic injuries
in the spine and lower extremities, skeletal
abnormalities in radiography tests, history
of surgery on the spine and lower
extremities, neuromuscular damage of the
spine and lower extremities, history of
rheumatoid arthritis disease, history of
ligament injuries in the joints of the spine
and lower extremities, history of fractures
in the spine and lower extremities, history
of spondylolisthesis, history of herniated
disc and unfinished evaluation programs.
According to the previous study (18) and
the power of 80%, the sample size was
determined as 120 subjects for each group.
The demographic data of the subjects were
recorded and their weight and height were
measured. The subjects’ weight was
measured without shoes and with light
clothes with 0.1 kg approximation. Their
height was measured without shoes, too.
The body mass index was calculated from
53
The correlation between mechanical low back
the related equation. In addition, patients’
pain intensity was measured by a Visual
Analogue Scale (VAS). VAS is a kind of
ruler with a length of 10 cm (Figure 1)
scaled from 0 to 10 where 0 means no pain
and 10 means very severe and unbearable
pain. It is worth noting that the intervals
between the numbers are scaled in
millimeters and the subjects put the marker
on the number corresponding to the
intensity of pain. In addition, the patients
were asked to rate their pain as numb,
tingling, burning and paresthetic; and to
express the duration of the pain. The two
groups were asked about having exercises
(regular exercise at least three times a
week) and answers that were recorded as
Yes or No.
The flexibility of the trunk was evaluated
by the flexion motion and measuring the
distance between the tip of the middle
finger and the ground. The patient was
asked to remove his shoes, stand up, and
lean forward as much as possible and to the
extent that they do not have pain. Then the
distance between the middle finger and the
ground was measured with a ruler and
recorded in centimeters (Figure 2).
In this study, ankle dorsiflexion range of
motion was evaluated on the basis of
America Academy of Orthopedic Surgeons
guidelines. In this regard, the patients lied
prone on the bed and bend their knee to 90
degrees. The examiner put the center of
goniometer on the external malleolus so
that the fixed axis of the goniometer was
along the fibula bone and the moving axis
was along the fifth metatarsal bone. The
patient was asked to perform the active
dorsiflexion motion. The angle of the
motion was recorded in degrees (20). The
normal dorsiflexion range is 10 to 20
degrees.
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017
Azar Moezy et al
The rear view of a flat foot indicates the
curving inward of the Achilles tendon
which is called the Helbing's sign. In order
to confirm the flat foot diagnosis or heel
valgus, the patients were asked to stand
with parallel feet and the angle of Achilles
tendon direction with the vertical line was
measured by goniometer and recorded
(Figure 3). The angle between the direction
of the Achilles tendon and the vertical line
is called the Helbing's angle. If it is more
than 20 degrees it is a sign of heel valgus
and flat foot (21).
In order to test the navicular drop, the
subjects were asked to sit on a chair with
bare feet and put their feet on a step so that
the angle of the hip and knee is 90 degrees
of flexion. In addition, during the
assessment, the hip was in a neutral position
without any lateral or medial rotation. Then
the examiner found the navicular
tuberosity, which is the outermost bony
bump on the inside of the leg and marked it
with a marker. Then the distance between
the navicular bone jut and the surface of the
stair was measured by a caliper and
recorded (mm). Then the patients were
asked to stand up and the distance between
navicular bone jut and the surface of the
stair was measured by a caliper and
recorded. The difference between the
distance of navicular bone and the stair in
the standing (weight-bearing) and sitting
(no weight) positions was considered as the
navicular drop (Figure 4). It should be
noted that the natural navicular drop level is
6-8 mm and amounts more than 8 mm are
considered abnormal and a sign of reduced
medial longitudinal arch (22, 23). Previous
studies have validated the navicular drop
test in the assessment of the medial arch and
reported a good to excellent repeatability
for it with the ICC test (0.83 to 0.95) (24-
26).
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The correlation between mechanical low back
Subjects with foot overpronation (flatfoot)
were identified according to the abnormal
amounts of Helbing's angle and navicular
bone drop, and their prevalence among the
study participants was determined.
In order to determine the rigid or flexible
type of the medial longitudinal arch
reduction, the subjects with reduced medial
longitudinal arch were asked to stand up
while all their feet sole was on the ground,
and once again stand on their toes. If there
was no medial longitudinal arch in a
weight-bearing condition, but it was visible
while standing on the toes, the flatfoot was
of the flexible type. Obviously, the medial
longitudinal arch is not visible in people
with rigid flat foot even when standing on
the toes.
The results were analyzed by SPSS
software version 18. The measures of
Figure 1
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017
Azar Moezy et al
central tendency and dispersion of the
studied variables were calculated to provide
descriptive statistics. At the beginning of
the statistical analysis, the demographic
variables of participants in both groups
were analyzed by the parametric
independent t-test. Lack of significant
differences in the variables indicated the
homogeneity of the study participants in
both groups (except in the case of the LBP
variable). Since the Kolmogorov-Smironov
test suggested the normality of the data, the
parametric independent t-test was used for
comparing the variables between the two
groups. The α level in this study was
considered as 0.05 with a power of 80%.
The chi square test was used to find the
relationships between variables.
55
The correlation between mechanical low back Azar Moezy et al

Figure 2

Figure 3

Figure 4

Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017

56
The correlation between mechanical low back
Results
The results of the independent t-test showed
that the study groups were homogeneous
with respect to age, height, weight and body
mass index (Table 1). Regarding gender
distribution between groups, there were 64
males and 57 females in the LBP group, and
62 males and 59 females in the control
group.
The history of LBP in the patients' group
was 4.27±1.91 years and the mean pain
intensity was 4.75±1.121 on the 0-10 basis.
The type of pain in patients with LBP was,
burning (35.5), tingling (19), paresthetic
(13.5), and numb (30).
The Helbing’s angle and the amount of
navicular bone drop were significantly
different between the patients with LBP and
the healthy controls (P=0.001 and
P=0.003). The amount of navicular bone
drop and Helbing’s angle was higher in
patients with mechanical LBP (Table 2).
The amount of physical activity in the LBP
and the control groups was 35.5% and
49.6#, respectively. The difference was
statistically significant (P=0.027) (Table 3).
It is worth noting that regarding the
incidence of LBP, the Odd Ratio was
0.5650 (confidence interval of 0.9384-
0.3348) which indicates a moderate
Table 1: Mean and SD of demographic variables in the study groups
Groups Patients with LBP
Demographic Mean
variables
Age (years) 36.44
Weight (kg) 75.84
Height (cm) 170.82
BMI (Kg/m2) 23.80
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017
Azar Moezy et al
correlation between the incidence of LBP
with physical activity.
As Table 4 shows, 8.26% of the control
group and 29.75% of the LBP group had
flatfoot or foot overpronation. The
independent t-test showed a statistically
significant difference between the two
groups (P=0.001). In the LBP group, 8
patients had rigid flatfoot 28 had a flexible
flatfoot. There were 10 cases of flatfoot in
the control group of which 3 had rigid
flatfoot and 7 had flexible flatfoot, which
indicates more prevalence of the flexible
flatfoot.
The chi-square test showed no significant
relationship between the flexibility of the
trunk (the distance between the tip of the
middle finger and the ground) and flatfoot
(P=0.087), while there was a significant
relationship between back pain intensity
and flatfoot (P=0.001). There was also a
significant relationship between the history
of back pain and flat foot (P=0.001). In
addition, based on the chi-square test, the
relationship between flatfoot and ankle
dorsiflexion range of motion was
significant (P=0.014). In other words, the
ankle dorsiflexion range of motion was
significantly lower in subjects with flatfoot.
Healthy controls P-value
SD Mean SD
8.83 36.06 8.35 0.096
8.28 74.71 7.683 0.092
9.394 167.95 10.29 0.089
1.39 23.11 1.08 0.097
57
The correlation between mechanical low back Azar Moezy et al

Table 2: Mean and SD in variables of the distance of the middle toe to the ground, ankle dorsiflexion range of
motion, Helbing’s angle, and navicular bone drop in the studied groups

Variables Patients with Healthy P-value

LBP controls
Mean SD Mean SD
Are the tip of the middle finger to 9.04 1.63 9.37 1.67 0.230
the ground (cm)
Ankle dorsiflexion range (degrees) 14.56 1.27 14.71 2.31 0.072
Helbing’s angle (degrees) 24.55 3.25 18.65 2.81 0.001
navicular bone drop (mm) 12.14 1.09 7.78 2.10 0.003

Table 3: Comparison of physical activity in the studied groups

Variable Patients with LBP Healthy controls P-value

Having physical activity 43 (35.5%) 60 (49.6%) 0.027
Lack of physical activity 78 (64.5%) 61 (50.4%)

Table 4: Comparison of flat foot in the studied groups

Variable Patients with LBP Healthy controls P-value

Flat foot 36 (29.75%) 10 (8.26%) 0.002
Natural foot 85 (70.25%) 111 (91.74%)

Discussion 16% had flatfoot. The frequency of LBP in

The main purpose of this study was to
investigate the relationship between
mechanical back pain and flatfoot or foot
overpronation in patients with LBP referred
to the Hazrat Rasool Hospital medical
complex in Tehran, Iran. The most
important finding of this study was that
8.26% of the control group and 29.75% of
the patients with mechanical LBP had
flatfoot, indicating a statistically significant
difference.
Babaei et al. found a significant relationship
between hallux valgus angle increase,
hallux rigidus and soleus muscle tightness
with chronic LBP. Although they did not
examine foot pronation, their results are
somewhat consistent with the present study
suggesting that the kinetic chain disorders
in the footsole have affected the lumbar
spine and caused chronic mechanical LBP.
In a retrospective study, Kosashvili et al.
(2008) examined 97,279 people of whom
the group without flatfoot was 5%, while it
was 10% in those with flatfoot. The
difference was statistically significant. It is
in line with the present study. This study
also showed the increasing prevalence of
flexible flatfoot in patients with LBP
compared to rigid flatfoot, which was
similar to the Kosashvili results (14).
Contrary to the findings of this study, an
analytic study by Menez et al. on 1930
people in the US in 2013 found no
relationship between the foot conditions
and musculoskeletal pain, especially back
pain.
The kinetic chain theory of Professor
Yanda must be considered in the
relationship between foot overpronation
and lower back mechanical pain. According
to this theory, a disorder in one limb can
affect other limbs and joints in the body.
Joints away from the area affected by
structural or functional disorder usually

Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017

58
The correlation between mechanical low back
compensate for the disorder and therefore
interfere with the normal pattern of weight
bearing and inappropriate distribution of
pressure, and chronic damages especially in
the musculoskeletal tissues. The structure
and function of the ankle and foot when
absorbing force and applying pressure have
a large influence on the upper parts of the
lower extremities and the trunk. Naturally,
the foot is the first limb that strikes the
ground and while reducing the ground
reaction force, prevents the transmission of
a lot of the pressure on the rest of the kinetic
chain. The pronation motions of the
subtalar and mid tarsal joint in three axes
when the foot touches the ground supports
the femur and tibia against the force by
changing the rotational torque. The support
protects the lower extremities from
damage. However, in the case of a flat foot,
the effective performance of foot in
meeting these requirements is greatly
distorted due to changes in the structure and
the arch of the foot (27).
In this study, there was no relationship
between the trunk and flatfoot flexibility in
LBP group, but back pain intensity was
considerably and significantly higher in
patients with flatfoot. The history of
mechanical LBP was significantly higher in
patients with flat foot. Moreover, the ankle
dorsiflexion range of motion has
significantly reduced in patients with flat
foot, which might be due to foot sole
deformation and reduced flexibility of soft
tissues, especially the abnormal position of
the Achilles tendon and its rigidity.
Naturally, foot range of motion was not
reduced in people with LBP and without
flat foot. On the other hand, decreased ankle
dorsiflexion is a factor that causes
mechanical LBP. This was in line with the
Brantingham (28). It appears that foot
overpronation which leads to decrease or
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017
Azar Moezy et al
fall of the medial longitudinal arch and
reduced ankle dorsiflexion ratio leads to the
collapse of the medial longitudinal arch.
The foot arches, especially the medial
longitudinal arch, create a reactionary
effect in the foot and have an important role
in absorbing shocks when the foot touches
the ground. In people with flat foot, during
walking and when taking the foot off the
ground, the hindfoot remains in the
pronation state and does not change to the
supination state, or has a little and very
delayed supination, which reduces the
absorption of pressure on the foot during
weight bearing. This can increase the risk of
pain and pain intensity in the central parts
of the musculoskeletal system. The findings
of this study indicated a statistically
significant relationship between flat foot
and the intensity of mechanical LBP.
On the other hand, the normal function of
the foot depends on the natural position of
the bones, joints, ligaments and muscles.
Any changes in the structure leads to
abnormal functions, exerting intense forces
in the joints and tissues of the lower
extremities, pelvis, and spine. In this case,
the foot cannot absorb the reaction forces
from the ground when standing, walking,
etc. These changes cause disorders in
walking and other kinetic chains of the
body. The kinetic chains are impaired due
to causes and mechanisms such as postural
disorders and improper body status,
repetitive patterns of motion, reduced
flexibility, fitness, biomechanical
deformation, etc. A typical example is the
changes in natural foot status in reduced
medial arc deformity and mechanical
lumbar pain (29).
Another finding of the study was the higher
rate of physical activity in healthy controls
compared to the LBP group. This indicates
the importance of exercise in maintaining a
59
The correlation between mechanical low back
healthy spine, increasing muscle strength
and improving body status and posture.
Few studies have examined the effects of
physical activity on the prevention of LBP
in Iran. Most of the available studies have
examined the effect of sports therapy on
controlling LBP. This was also emphasized
in the Bell’s review study (30). Vuori et al.
had also similar findings and showed that
physical activity is effective in the
prevention of LBP, but finding the exact
intensity of physical activity that would be
effective in this regards needs further
investigation (31).
One limitation of the study was not
examining the effect of type of physical
activity on the prevention of LBP. The
study was limited to the presence or
absence of physical activity. Another
limitation of this study was not examining
other relevant factors, in particular, lower
extremity biomechanical disorders and
changes in the soft tissues lengths with
LBP. Undoubtedly, body status and posture
examination in the LBP group is essential,
which was another limitation of this study.
Due to the paucity of studies on the
relationship between the kinetic chains in
the musculoskeletal system and pain in
musculoskeletal disorders, it is
recommended that further studies be
conducted in this area, particularly with a
longitudinal structure with multicenter to
complete this study and remove its defects.
The examination of the relationship
between other joints of the lower
extremities and the tightness of foot soft
tissue in patients with LBP, as well as
examination of the relationship between
Pars Journal of Medical Sciences, Vol.14, No.4, Winter 2017
Azar Moezy et al
regular physical activities and back pain
can be beneficial in the prevention of spinal
pain. However, it should be noted that
examination of flat foot, physical activity,
the distance of the tip of the middle finger,
etc. variables in healthy individuals can be
important in predicting LBP.
Conclusion
The results of this study suggest a
relationship between the incidence,
severity, and duration of LBP in patients
with flatfoot. In addition, ankle dorsiflexion
range of motion in patients with flatfoot or
foot overpronation was lower. The results
showed that regular physical activity is
effective in the prevention of mechanical
LBP.
Acknowledgments
This present study was extracted from a
general practitioner's thesis titled "the
correlation between mechanical low back
pain and foot overpronation in patients
presenting to Hazrat Rasool Hospital"
(code 8721215095). The compliance with
the principles of research ethics and
provisions in the proposal of Iran
University of Medical Sciences was
approved by the Research Ethics
Committee. The authors sincerely
appreciate the cooperation of all
participants in the study.
Conflict of Interest
The authors have no conflict of interest in
relation to the writing and publication of
this article.
60
The correlation between mechanical low back
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